Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 3 of 19 (Patients #2,#8,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: Upon home visit medication reconciliation, the patient did not have donepezil in the home. Additionally there were several medications in the home that were not included in the hospice medication profile including Icy Hot, MiraLAX, milk of magnesia, aspirin, vit B12, Benadryl, cetirizine, Excedrin, meclizine, and Tums. Corrected on site with nurse education to the patient and reconciliation with the physician. Patient 8: Upon home visit medication reconciliation, the patient's daughter responsible for medication administration stated the patient was no longer taking aspirin and it had been discontinued. The medication profile listed the aspirin as current. Corrected on site. Patient 9: Upon home visit medication reconciliation, the facility medication profile contained acetaminophen, milk of magnesia, sennosides and tramadol PRNs that were not on the hospice profile. The facility and hospice doses for quetiapine also differed with facility instructions for 75 mg three times daily and hospice instructions for 50 mg three times daily. Corrected on site.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3: The initial bereavement assessment was completed 3/7/25 with start of care 2/27/25.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained nursing documentation upon admission identifying patient had a history of recent fall with abrasion to head and documentation 2/28/25 identifying need for assistance with standing. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site.

Upon patient record review, 2 of 19 (Patient #2,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: Upon home visit medication reconciliation, there were several medications in the home not ordered on hospice plan of care including Icy Hot, MiraLAX, milk of magnesia, aspirin, vit B12, Benadryl, cetirizine, Excedrin, meclizine, and Tums. Corrected on site with nurse education to the patient and reconciliation with the physician. Patient 9: Upon home visit medication reconciliation, the facility medication profile contained acetaminophen, milk of magnesia, sennosides and tramadol PRNs that were not ordered on hospice plan of care. The facility and hospice doses for quetiapine also differed with facility instructions for 75 mg three times daily and hospice instructions for 50 mg three times daily. Corrected on site.

Upon patient record review, 3 of 19 (Patients #2,#7,#10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 2/17/25 identifying patient use of oxygen and a Hoyer lift. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 12/16/24 identifying patient use of bedrails, commode and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #10,#12,#13) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 10: The plan of care contained active problems, goals, and interventions to be addressed by the chaplain. Chaplain services were discontinued 3/2/25. Corrected on site. Patient 12: The plan of care contained active problems, goals, and interventions to be addressed by the chaplain. Chaplain services were discontinued 10/30/24. Corrected on site. Patient 13: The plan of care contained active problems, goals, and interventions to be addressed by the social worker. There was no evidence or social work services except an initial assessment. Corrected on site.

Upon client record review, 1 of 19 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained an order for indwelling foley catheter size 20 Fr with 10 ml balloon. Nursing documentation 2/22/25 identified placement of a catheter size 18 Fr, and 3/23/25 size 16 Fr catheter was inserted.

Upon patient record review, 2 of 13 records (Patients #3,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient 3: The medication profile contained two scheduled listings for lorazepam; daily at bedtime and every 4 hours. Corrected on site. Patient 7: The medication profile contained an albuterol inhaler PRN listed three times. One every 4 hours as needed, one twice daily as needed, and one four times daily as needed. Corrected on site.

Upon patient record review, 2 of 13 records (Patients #11,#13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within 5 days of the election of hospice. Patient 11: The medical record contained initial bereavement assessment dated 3-1-22. Patient admitted to hospice services 5-13-21. Patient 13: The medical record contained initial bereavement assessment dated 4-6-21. Patient admitted to hospice services 3-31-21.

Upon patient record review, 3 of 13 records (Patients #3,#4,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: The medical record contained two scheduled orders for lorazepam; daily at bedtime and every 4 hours. Corrected on site. Patient 4: The medical record contained an order for oxygen to be delivered via nasal cannula. Nursing documentation 3/22/22, 4/12/22, and 4/15/22 identified oxygen delivery method was a mask. There was not an order to deliver O2 via mask. Corrected on site. Patient 7: The medical record contained three orders for an albuterol inhaler PRN. One every 4 hours as needed, one twice daily as needed, and one four times daily as needed. Corrected on site.

Upon patient record review, 3 of 13 records (Patients #1,#8,#9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medication list contained albuterol ordered for nebulization. There was no evidence of a nebulizer included as DME on the plan of care. Corrected on site. Patient 8: The medication list contained duoneb ordered for nebulization and patient use of walker identified by nursing documentation upon admission. There was no evidence of a nebulizer or walker included as DME on the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 1-27-22 identifying patient use of walker. There was no evidence of the walker included as DME on the plan of care. Corrected on site.

Upon patient record review 1 of 11 applicable records (Patient #13) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG. Patient 13: The medical record contained an aide visit frequency of twice weekly. There was no evidence of any aide visits completed the week of 1-30-22 and one visit completed the week of 2-20-22. There was no evidence of documentation why the visits were not completed or orders to change frequency.

Upon patient client record review, 1 of 13 (Patient #11) did not evidence that each patient record contains physician orders. Patient 11: The medical record contained a discharge summary identifying the patient was discharged due to extended prognosis. There was no evidence of an order to discharge.

Upon personnel record review, 2 of 4 applicable records (Personnel #13,#14) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 13 and 14: The agency was unable to obtain background checks on the PT and OT from the contracted agency.